By the WoundSource Editors

A wound specialist’s job is to outline the options available for treatment. It is the patient’s job to choose a treatment option. Patients do not even have to select the best option. They must choose an option that works for them given their unique circumstances having a wound. When it comes to selecting debridement methods there are several options to choose from. This article will provide an overview of the most common debridement methods.

Methods of Debridement

Sharp debridement uses instruments such as forceps, scalpels, curettes, scissors, or a combination of instruments to remove non-viable tissue and biofilm from the wound bed. With this method of debridement, anticoagulant use is a contraindication, or at least laboratory tests should be checked prior to debridement. Providers should consider pain management before and during the procedure if the patient has sensation in the area. This method may be contraindicated for areas that have inadequate perfusion such as an ischemic limb. This form of debridement requires someone trained and skilled under their scope of practice (usually a doctor, nurse practitioner, physician assistant, certified wound specialist, etc).¹

Other surgical debridement methods include laser and hydrosurgical methods, both of which are non-selective. Laser debridement, which is not widely available, utilizes focused pulsing beams of light, with each wavelength being specific to a type of tissue; targeted tissue contains chromophores that absorb the laser energy and are vaporized. This method sterilizes the wound bed and cauterizes bleeding, but poses risk of injury to healthy tissue (pulsed beams decrease this risk as opposed to continuous beams). Hydrosurgical debridement uses a handpiece connected to the main control unit and forces high-power normal saline through a probe tip producing a precise, focused stream of fluid parallel to the wound surface. This stream returns through the handpiece along with liquified tissue and is disposed of in a collection container. This method should be used only in surgical settings and its efficacy is limited to lower extremity ulcers and burns. Hydrosurgical debridement offers efficient debridement for contoured areas and difficult topography.^{2, 3}

Enzymatic debridement refers to the application of a biological enzyme that selectively attacks non-viable tissue. This method of debridement usually includes a once a day (or more often) application and currently requires a prescription . This method is easy to use and not difficult to apply. Despite access to enzymatic debridement for decades, there have been minimal reported side effects or negative events. This method does require a moist wound environment to help the enzyme be active and effective. It is important to know which wound cleansers and surfactants inactivate or diminish the activity of this product. Enzymatic debridement does not address bacterial load or biofilm in the wound bed, but it is ideal to use with a synergistic approach (discussed later).¹

Autolytic debridement uses dressings designed to create a moist healing environment while supporting the body’s natural debridement ability. It is the slowest method of debridement but allows passive and selective removal of necrotic tissue. These dressings are easy to apply. Some dressings assist with odor control, aid in bleeding control, have longer wear times, and help with comfort. Some dressings help with bioburden removal and work well with sharp and enzymatic debridement.¹

Mechanical debridement uses physical force to remove non-viable tissue. It can be fast and effective or slow and less effective depending on the modality used for mechanical debridement. It removes non-viable and viable tissue non-selectively. Some methods can cause pain and increased bleeding, so clients receiving anticoagulant therapy or with painful wounds may want to consider other options. Some methods work well for biofilm control. Certain methods of mechanical debridement (such as pulse lavage) may require special knowledge or training on equipment. This method works well with a synergistic approach.¹

Biosurgical debridement is the term used for applying sterile larvae (maggots) to a wound with dead or non-viable tissue. Maggots selectively remove non-viable tissue without damaging healthy tissue. This is considered a fast and effective approach to debridement but can be psychologically disturbing for some clients, family, and even staff. This method is contraindicated in some wound types, such as open abdominal wounds, wounds infected with Pseudomonas aeruginosa, pyoderma gangrenosum, or where staff is not trained to perform or oversee this debridement method. To maintain the viability of the maggots, the wound must be free of external pressure. Wounds need to be moist, and an accurate log of when the maggots were applied versus when they need to be removed must be kept.¹

Synergistic debridement combines several methods of debridement to remove necrotic tissue. Efforts can be simultaneous and ongoing or used for a limited time only. By combining methods, the debridement plan can be tailored to the client’s individual choice, clinical situation, environmental challenges, or wound requirements. Multiple specialties may be involved in the synergistic approach such as the nurse, the wound specialist, and therapist. Synergistic debridement is a favorite because multiple issues are usually treated at the same time (e.g., biofilm removal, necrotic tissue, healthy tissue salvage), and this approach can allow the wound the greatest chance to heal versus stalling out.¹

What Not to Debride

Current standard of care guidelines recommend that stable, intact (dry, adherent, intact without erythema or fluctuance) eschar on the heels should not be removed. Poor blood flow beneath the eschar warrants high susceptibility to infection. Eschar works as a natural barrier protecting the wound bed from bacteria. If the eschar becomes unstable (wet, draining, loose, boggy, edematous, red), it should be debrided according to the clinic or facility protocol.⁴

Autoimmune and pyoderma gangrenosum wound types tend to worsen with sharp debridement when there is a prominent, active border. This is the result of triggering an inflammatory response known as “pathergy."⁵ Patients receiving immunosuppressive therapy, with non-active border clinical signs as mentioned, can receive surgical debridement.⁶

Calciphylaxis wounds with expanding tissue necrosis and a violaceous border should not be surgically debrided. The patient must also complete sodium thiosulfate therapy, along with clinical observations that necrosis expansion has stopped, and the violaceous border is no longer present.⁶

Conclusion

Not every method of debridement is right for every patient. Many patients are unable to tolerate biosurgical debridement (nor can some clinicians, for that matter), and still others do not have the tolerance for sharp debridement. There are different debridement methods for different settings: what works in the hospital setting may not be ideal for the long-term care setting. The best that wound care clinicians can do is make sure patients are aware of the options available to them, and just what each option entails.

Reference
1. Ayello E, Chapman F, Kelso M, et al. Debridement: clinicians resource guide. Smith&Nephew. 2016. https://img1.wsimg.com/blobby/go/8a2113b4-c204-4308-a16b-61c274519e97/d…. Accessed on March 5, 2019.
2. Baronoski S, Ayello A, eds. Wound Care Essentials: Practice Principles, 4th ed. Philadelphia: Wolters Kluwer; 2015; Bryant R A, Nix DP. Acute and Chronic Wounds: Current Management Concepts, 3rd ed. St. Louis, MO: Elsevier Mosby; 2007; DeRoyal. Jetox™- ND jet lavage wound cleansing & debridement system. http://www.deroyal.com/medicalproducts/woundcare/product.aspx?id=wc-adv…. Accessed April 11, 2019.
3. Draeger, RW, Dahners LE. Traumatic wound debridement: a comparison of irrigation methods. J Orthop Trauma. 2006;20:83–8; Krasner D, ed. Chronic Wound Care: The Essentials. Malvern, PA: HMP Communications; 2014.
4. Carver C. Knowing the Difference Between Scab and Eschar. WoundSource.com. 2016. http://www.woundsource.com/blog/knowing-difference-between-scabs-and-es…. Accessed April 11, 2019.
5. Suzuki K, Cowan L. Current concepts in wound debridement. Podiatry Today 2009;22(7:40–8. Available at: https://www.podiatrytoday.com/current-concepts-in-wound-debridement. Accessed April 11, 2019.
6. Carpenter S, Shaffett TP. Choosing the Best Debridement Modality to ‘Battle’ Necrotic Tissue: Pros & Cons. Today’s Wound Clinic. 2017;11(7).

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.